Cognitive Behavioral Therapy

Introduction

The agency’s mission is to create an organization that leads the standards of excellence in supporting and treating adults, children, and families. To families, the agency is committed to providing individualized support and treatment plan to regain hope and promote empowerment. To in-home providers, the agency is committed to fostering an environment that encourages and supports professional and personal growth.

The organization’s vision is to be recognized as the leader in support services and behavioral healthcare based on the agency’s understanding and commitment to the following; dignity, respect, and compassion for all people. The importance of family and community working together. The application and utilization of evidence-based practices and professional excellence through ongoing training and Continuous Quality Assurance.

The agency wants to see a world of opportunity and inclusion where every individual can thrive in all aspects of life. The agency wants everyone to feel accepted, valued, heard, and respected. There is no place for poverty-induced shame in the agency. As an agency committed to ensuring every individual gets the best possible end-of-life experience, the agency cannot stay quiet about income inequality. Some issues bind all individuals facing prejudice; therefore, the agency is committed to working for equity, diversity, and inclusion to address intersectionality. Regardless of race, every individual should be able to be their best self without being discriminated against or judged. The agency works with individuals from different races, such as Black, Asian, and Latino. The main social problem faced by the diverse group is poverty-induced shame.

The agency uses an evidence-based intervention known as Cognitive Behavioral Therapy when working with a diverse group. Cognitive behavioral therapy, also known as CBT, is a form of psychological treatment effective for several problems, such as depression, anxiety, substance and alcohol use, and marital issues. Research indicates that CBT significantly improves functioning and quality of life. CBT in treatment enables clients to take control and ownership to recover. In therapy, therapists have to develop a rapport with clients and discuss their triggers and defense mechanisms when addressing clients’ illnesses. However, intervention treatment can only be successful if clients are willing to put in the effort when tasks are assigned to them by therapists.

CBT addresses mental disorders through different treatment methods based on the client and their needs. CBT in illness focuses on negative thought patterns that demonstrate unhealthy behaviors and how individuals see themselves and others in the world around them. CBT for mental health illnesses is treated based on what circumstances trigger behaviors that lead to the illness and disorder. A CBT therapist identifies situations that create the stressors and situation within a client’s life that causes the disease. Once the problems are determined, the therapist looks into the current thought patterns and distorted perceptions to treat the client.

Literature Review

As mentioned earlier, the agency deals with poverty-stricken individuals from different races, including Black, Asian, and Latino. Shame is a social dimension of poverty (Jo, 2013). Shame lies at the core of poverty; shame refers to a self-conscious and moral emotion opposed to basic emotions like anger. In relation to poverty, shame can take different forms. For example, not being in a position to meet one’s necessities is accompanied by shame, even more when it comes to not being able to provide for one’s children. Shame induced by poverty can have different negative impacts, such as low self-esteem and withdrawal from society, in most cases perpetuating the vicious cycle of poverty even more.

Shame hurts and undermines individual agency, adding to the negative impact of poverty and its perpetuation (Walker & Bantebya-Kyomuhendo, 2014). In worst-case scenarios, poverty can lead to depression and suicide. Zhong, Wang, Qian et al., assert that shame can lead to mental illnesses such as anxiety (2008). Cheung, Gilbert & Irons assert that shame can lead to depression (2004). On the other hand, Dickerson, Kemeny, Aziz et al., posit that shame has effects on physiological health, including having an impact on immunological functioning (2004). Since shame has such a detrimental effect on a diverse population finding an effective intervention to treat and alleviate feelings of poverty-induced shame is very important. In this research paper, the focus will be on cognitive behavioral therapy. Before evaluating how effective CBT is in helping the diverse population suffering from poverty-induced shame, two of shame’s main symptoms will be examined.

According to Van Vliet, shame is elicited as a response to social rejection and other events that interfere with an individual’s self-esteem, social status, and sense of acceptance (2008). Gruenewald and Kemeny, Aziz & Fahey found a link between an increase in shame and a decrease in self-esteem (2004). Hall & Tarrier suggested a form of CBT to target low self-esteem (2003). The results of their study indicate that CBT can effectively improve a client’s self-esteem, which, given the strong connection between low self-esteem and shame, would also mean that CBT would positively impact clients experiencing shame.

Another study by Taylor & Montgomery looked into how efficiently CBT improved self-esteem (2007). Their research found that even though CBT did not lead to an increase in self-esteem, the increase was not clinically significant. The researchers, however, found that in a five-week follow-up, participants’ self-esteem continued to rise. This suggests that CBT may lead to a gradual increase in self-esteem and so could offer a long-term solution for clients experiencing shame.

Shame is a broken connection between an individual and others. A break of understanding expectations and acceptance is needed for a sense of being a valued member of the human family (Leeming & Boyle, 2004). The author posits that the cure for shame is empathy. The two main focus areas in CBT are cognitive restructuring and behavioral activation. These two areas are achieved by assigning homework to clients after each appointment. According to Vyskocilova, Prasko, & Slepecky, cognitive behavioral therapists demonstrate genuine empathy, respect, care, and accurate understanding (2011). In 1992, Burns & Nolen-Hoeksema researched the role of empathy in CBT when holding clients with depression. The researchers found that clients rated novelty therapists as less empathetic compared to more experienced therapists.

However, since the research was done, education and training therapists have constantly improved, and more recent studies have focused on the role of empathy in other core conditions in the therapeutic relationship. With regards to clients experiencing shame, the abovementioned research indicates some conflicting results. However, with reference to Burns & Nolen-Hoeksema’s research, it would indicate that experienced therapists are essential when handling clients who experience shame because empathy is essential when treating shame.

Methods

Sample Description

The interview was conducted by interviewing five professionals. The five professionals were interviewed individually, and the interviews were done face-to-face. The interviewees include a clinical director, a clinical supervisor, two therapists, and a behavioral assistant. These interviewees were chosen because, as mentioned earlier, the agency uses CBT to help a racially diverse client group that struggles with shame caused by poverty. All the participants of the interview have, in one way or another, interacted with CBT or dealt with a diverse group. Therefore, they were the best people for the interview.

The interviews were conducted at a time and place of the interviewees’ convenience and in comfortable settings that were free of potential disruptions. Two interviewees preferred the interviews to be done in their offices, while the other three chose a quiet park where the interviews were done. Each interviewee was allocated thirty minutes to answer all the interview questions. During the interview, each interviewee was presented with identical questions regarding Evidence-Based Interventions and requested to respond to each question in writing for transcribing purposes.

Results

Themes

Theme One: The interviewees, in one way or another, help clients work through their challenges and become better people. One of the interviewees responded that they serve the role of a Therapist/ Intensive In-Community Counsellor.

Theme Two: All the interviewees are certified, licensed, or qualified. For instance, Therapist 1 has MS in Mental Health Counseling.

Theme Three

The five professionals use different psychotherapy interventions to help clients change behaviors and become better people. The clinical Supervisor says, “Child Parent Psychotherapy (CPP) is used with youth from birth to age 5. This is used to support parents in effectively building a positive dyadic relationship with their child and better understand their responses to trauma. Cognitive Behavioral Therapy (CBT) is used with clients of all ages with a heavy focus on understanding the relationship between their thoughts, feelings, and actions (CBT triangle). This helps validate feelings and understand healthy responses.”

Theme Four

Clients are unwilling to commit to the process because of their cultural beliefs and shame. Therapist 2 states, “In some cultures, psychotherapy is received with a negative stigma. Some families and cultures don’t talk about their “family business” to outsiders, which is counterproductive to self-disclosure and processing traumatic events.”

Theme Five

Cognitive Behavioral Therapy is the most effective evidence-based intervention when treating clients with mental health issues such as anxiety, depression, and post-traumatic disorder. The Clinical Supervisor states, “I have seen the most success using CBT with teenagers who have depression and anxiety. After the cognitive behavioral triangle is understood, clients have been able to identify these emotions and some simple healthy coping skills such as self-talk, reframing thinking, and using healthy social support systems.”

Theme Six

A major cultural adaptation that needs to take place is cultural competence. Therapist 2 states, “Cultural competence is very important, particularly when serving the youth and families impacted by adversity and inequities. Cultural adaptation should consider language, culture, and contacts in such a way that is compatible with the youth and families’ cultural patterns, meaning, and values.”

After analyzing the interview data, the principal codes include shame, client resistance, negative stigma, and non-commitment to the process. From the codes, the themes obtained include shame, non-commitment to the process, and stigma.

Non-commitment to therapy is a prevalent problem in psychotherapy. Non-commitment to the process refers to anything that stops therapeutic change. Non-commitment is the client’s unwillingness, consciously or unconsciously, to grow. No matter how much effort a counselor puts in, some clients fail to act in their best interest and negatively respond to all counseling interventions. Such clients are, in most cases, referred to as non-compliant or not committed. The behaviors displayed by such clients are usually referred to as resistance (Otani, 1989). In clinical definition, resistance refers to the process of avoiding or diminishing self-disclosing communication asked by the interviewer because of its capacity to make the interviewee uncomfortable.

Non-commitment to the process is a fundamental obstacle to positive counseling outcomes because resistance interferes with the counselor’s perceived efficacy and undermines the change process. Resistance is the client’s defense mechanism of attempting to block or repress anxiety-provoking memories and insights from entering conscious awareness. Behavioral theorists view resistance as client noncompliance. Behaviorists believe that a client shows resistance because they do not have the necessary skills or knowledge to follow behavioral assignments. Resistant behaviors could result from the client having negative expectations or beliefs about counseling outcomes and being subjected to undesirable environmental conditions.

Stigma refers to negative attitudes or discrimination against an individual based on a distinguishing characteristic such as poverty. Social stigmas can also be related to other characteristics, including race. There is a public stigma associated with having a mental illness. Other than beings stigmatized for having a mental illness, individuals are stigmatized for seeking professional help. Seeking professional psychological help is regarded as a disgrace. For instance, when the therapist was asked what barriers they have encountered when using CBT, they mentioned that some cultures receive psychotherapy with a negative stigma. Some individuals are not comfortable sharing their issues with a third party. When clients are unwilling to talk about their issues openly, it becomes challenging for them to process traumatic events in their lives.

All the subthemes mentioned above revolve around an individual being ashamed or feeling the need to be ashamed. Therefore, the central theme obtained from the data is shame. The theme is the most suitable because the qualitative research is about poverty-stricken, racially diverse individuals and the impact that poverty has on their mental health. Shame refers to embarrassment or humiliation caused by the perception of having done something wrong, immoral, or inappropriate. According to Adam Smith, shame is a social dimension of poverty. Shame lies at the core of poverty; shame refers to a self-conscious and moral emotion opposed to basic emotions like anger. In relation to poverty, shame can take different forms. For example, not being in a position to meet one’s necessities is accompanied by shame, even more when it comes to not being able to provide for one’s children. Shame induced by poverty can have different negative impacts, such as low self-esteem and withdrawal from society, in most cases perpetuating the vicious cycle of poverty even more.

Individuals living in poverty can be uniquely vulnerable to shame for several reasons. Poverty entails increased vulnerability from unexpected negative shame like the sudden loss of a source of income. Research indicates that adverse economic shocks can negatively affect an individual’s mental health. In addition, conditions of poverty are taxing on mental resources, with the amount of mental bandwidth spent on handling short-term economic issues reducing cognitive resources for making decisions in other reals. Therefore, mental health care has significant positive impacts on low-income, racially diverse populations.

CBT, as mentioned earlier, is a common clinical approach to mental health that aims to improve a wide range of harmful beliefs and behaviors by addressing clients’ thought patterns. For instance, a therapist using CBT might assist a client in understanding when they are mentally overemphasizing poverty to the extent of feeling shame for not being able to afford basic needs. The therapist can then propose strategies to disrupt the thought pattern in favor of those better for the patient’s well-being. Since individuals living in poverty are vulnerable to shame, CBT may be impactful in improving mental health in racially diverse poor communities. CBT might also address the issue of limited bandwidth that can happen regardless of mental distress leading to improved decision-making and financial results.

Discussion

As mentioned earlier, the agency deals with poverty-stricken individuals from different races, including Black, Asian, and Latino. According to Adam Smith, shame is a social dimension of poverty. The qualitative analysis shows that CBT is the most effective when treating a diverse poverty-stricken population dealing with shame. Research indicates that CBT significantly improves functioning and quality of life. CBT in treatment enables clients to take control and ownership to recover. In therapy, therapists have to develop a rapport with clients and discuss their triggers and defense mechanisms when addressing clients’ illnesses. However, intervention treatment can only be successful if clients are willing to put in the effort when assigned tasks.

Shame lies at the core of poverty; shame refers to a self-conscious and moral emotion opposed to basic emotions like anger. With relation to poverty, shame can take different forms. For example, not being in a position to meet one’s necessities is accompanied by shame, even more when it comes to not being able to provide for one’s children. Shame induced by poverty can have different negative impacts, such as low self-esteem and withdrawal from society, in most cases, perpetuating the vicious cycle of poverty even more.

Based on the literature review, the agency is on the right track with regard to using CBT to treat a diverse population. According to Robert Walker’s extensive research, shame hurts and undermines individual agency, adding to the negative impact of poverty and its perpetuation. In worst-case scenarios, poverty can lead to depression and suicide. Zhong, Wang, Qian et al., assert that shame can lead to mental illnesses such as anxiety. Cheung, Gilbert & Irons assert that shame can lead to depression. At the same time, Dickerson, Kemeny, Aziz et al., posit that shame has effects on physiological health, including having an impact on immunological functioning.

The agency acknowledges the mental illness associated with poverty, and the possibility of the clients having such illnesses is considered when handling clients. In addition, living with the fact that an individual cannot afford basic needs such as food and accommodation is not easy. Therefore, low self-esteem is a significant problem for the diverse client group handled by the agency. CBT comes in handy for clients experiencing self-esteem because once an individual has low self-esteem, they tend to develop mental health illnesses such as depression and anxiety.

From the literature review, according to Vyskocilova, Prasko, & Slepecky, cognitive behavioral therapists demonstrate genuine empathy, respect, care, and accurate understanding. Professionals at the agency are always encouraged to be empathetic with their clients because empathy is fundamental in CBT. Professionals at the agency must be empathetic but not sympathetic because sympathy does not help clients work through their issues. In 1992, Burns & Nolen-Hoeksema researched the role of empathy in CBT when holding clients with depression. The researchers found that clients rated novelty therapists as less empathetic compared to more experienced therapists. Recently, the agency has hired many new therapists; therefore, the agency needs to create a balance between hiring new therapists and well-experienced therapists. This is because based on Burns & Nolen-Hoeksema’s research, well-experienced clients are more empathetic compared to novelty therapists.

References

Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: a structural equation model. Journal of consulting and clinical psychology, 60(3), 441.

Cheung, M. P., Gilbert, P., & Irons, C. (2004). An exploration of shame, social rank, and rumination in relation to depression. Personality and Individual Differences, 36(5), 1143-1153.

Gruenewald, T. L., Kemeny, M. E., Aziz, N., & Fahey, J. L. (2004). Acute threat to the social self: Shame, social self-esteem, and cortisol activity. Psychosomatic Medicine, 66(6), 915-924.

Hall, P. L., & Tarrier, N. (2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study. Behaviour research and therapy, 41(3), 317-332.

Jo, Y. N. (2013). Psycho-social dimensions of poverty: When poverty becomes shameful. Critical Social Policy, 33(3), 514-531.

Kemeny, M. E., Gruenewald, T. L., & Dickerson, S. S. (2004). Shame as the emotional response to threat to the social self: Implications for behavior, physiology, and health. Psychological Inquiry, 15(2), 153-160.

Leeming, D., & Boyle, M. (2004). Shame as a social phenomenon: A critical analysis of the concept of dispositional shame. Psychology and Psychotherapy: Theory, Research and Practice, 77(3), 375-396.

Otani, A. (1989). Client resistance in counseling: Its theoretical rationale and taxonomic classification. Journal of Counseling & Development, 67(8), 458-461.

Pyrczak, F., & Tcherni-Buzzeo, M. (2018). Evaluating research in academic journals: A practical guide to realistic evaluation. Routledge.

Taylor, T. L., & Montgomery, P. (2007). Can cognitive-behavioral therapy increase self-esteem among depressed adolescents? A systematic review. Children and Youth Services Review, 29(7), 823-839.

Van Vliet, K. J. (2008). Shame and resilience in adulthood: A grounded theory study. Journal of counseling psychology, 55(2), 233.

Vyskocilova, J., Prasko, J., & Slepecky, M. (2011). Empathy in cognitive behavioral therapy and supervision. Activitas Nervosa Superior Rediviva, 53(2), 72-83.

Walker, R., & Bantebya-Kyomuhendo, G. (2014). The shame of poverty. Oxford University Press, USA.

Zhong, J., Wang, A., Qian, M., Zhang, L., Gao, J., Yang, J., … & Chen, P. (2008). Shame, personality, and social anxiety symptoms in Chinese and American nonclinical samples: a cross‐cultural study. Depression and anxiety, 25(5), 449-460.

Appendix

Interview Demographics Information

Clinical Director

Age: 50 Years

Gender: Female

Length of time in current position: 10 Years

Race: Hispanic

Certification/ Degree: Master in Social Work/ LCSW, Master in Criminal Justice with a Concentration on Applied Behavioral Analysis/ BCBA

Clinical Supervisor/ Therapist

Age: 35 Years

Gender: Female

Length of time in current position: 5 Years

Race: White

Certification/ Degree: LCSW

Therapist 1

Age: 45 Years

Gender: Male

Length of time in current position: 10 Years

Race: Black

Certification/ Degree: MS in Mental Health Counselling

Therapist 2

Age: 40 Years

Gender: Male

Length of time in current position: 10 Years

Race: Black

Certification/ Degree: Master’s degree in Psychology

Behavioral Assistant

Age: 31 Years

Gender: Male

Length of time in current position: 5 Years

Race: Black

Certification/ Degree: Behavioral Assistant Training Certification